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Cheap as Free Learning: Personality Disorders

You can learn much much much more for free on the internet than paying hundreds of dollars to go to professional seminars if you know where to look and who to trust. Reddit is amazing for this. Here’s a psychiatrist who specializes in personality disorders explaining personality disorders! Dr. Peter Freed of the Personality Studies Institute was a sweetheart and took his doctor time off to answer questions. Here are some good ones:

On the idea that there is no treatment for sociopaths:

That’s a myth. There is absolutely treatment for sociopathy. Many people who say there isn’t are secretly talking about very high-end sociopaths who are consciously and contentedly sadistic and criminal. But there is a very large group of sociopathic individuals who want to be part of normal society, but simply find they lack the normal guilt and empathy feelings that help neurotypicals automatically fit in. For them the treatment involves a long-term supportive treatment designed to help them work around their natural tendency to not really care how other people feel. It involves a lot of psychoeducation (at first), letting key family members or loved ones in on their diagnosis, and coming up with a game plan for avoiding legal trouble. Once these things are in place, they can start talking through specific incidents (eg shoplifting, lying, feeling empty when something bad happens to another person) in an effort to see whether there are little flickers of empathy and guilt. I have found that these “embers” of empathy and guilt can be slowly heated up. I have seen several patients go on to happy lives and happy relationships. Going into fields of work where sociopathy is an asset can be helpful. A review of famous world leaders, athletes, businessmen will reveal many personalities who sound, on close reading, as though they have sociopathic tendencies. Not all of them are “evil” by any means. Reconceptualizing sociopathy as “trouble feeling guilt or empathy” is a useful first step to helping them. That said, the treating MD and everyone else must remain ever vigilant for signs that they are being mistreated, and forthrightly and directly confront aggression. Staying silent, letting things pass, or telling yourself it must be your mistake never helps the patient.

On the breakdown of how personality disorders are distributed:

Of every 100 patients referred to me I’d guess I end up thinking maybe 5 are schizotypal and 5 are schizoid, while I find maybe 50 are narcissitic and 30 are borderline and maybe 10 are something else.

~50% of all PD patients are NPD, and BPD makes up only 30%. But reading the popular press you’d think BPD >> NPD.

How to tell if your crazy is a bad kind of crazy:

Psychiatry divides patients into – more or less – two categories. The first know that they have problems, and describe them to the doctor, and the doctor agrees, and then they both work on the problem together. These are called ego-dystonic disorders, because the patient knows that they aren’t normal or right or healthy (or something like that). Ego-dystonic means something like “against the self.” Anxiety is the classic example of an ego-dystonic disorder: the patient can’t stand feeling anxious. The second don’t know that they have problems, and don’t think they need a doctor, or if they do see a doctor describe some other problem that is not their “actual” problem. These disorders are called ego-syntonic, because they are “with the self,” meaning the person thinks the problem is them, or they are the problem, and they like themselves, and therefore don’t think they have a problem. As you can imagine it is much harder for the doctor to help this patient, because the patient only dimly knows they have the problem. Sometimes people use addiction as an example of ego-syntonic disorders (eg, the alcoholic sahing “I don’t have a problem”) but I prefer the example of the person who complains about not having a boyfriend but then, when a man likes her, pushes him away. She doesn’t realize she is pushing him away, and in fact may defend herself when her mom tells her something like “don’t you think you should dress up for your date tonight?”; she may say it is her right to wear sweatpants and no makeup on a date, and she wants a man to like “me for me, not my mascara.” Thus her mom is left worrying her daughter is sabotaging her date, while the woman herself is indignant at this criticism. For this latter type of person, what is typically needed is to get what’s called “collateral history.” You (or sometimes the patient) interview friends, family members, lovers, children and ask them what the patient is like. If everyone identifies a certain theme – “she gets mad really easy,” or “I feel like I’m walking on eggshells around her” or “she’s not very reliable” or “she doesn’t follow through on her promises” – that’s a sign that there is an ego-syntonic problem.
Combining these two approaches – asking the patient (or yourself) what’s wrong, and asking important (and trusted) others in your life if they have any concerns – usually tells you if there are problems. If you are happy, and the people in your life are happy with you, it’s very doubtful there are problems.

How to tell if you’re dealing with a personality disorder:

The main thing to realize is that when diagnosing personality disorders the doctor does not try to diagnose particular disorders. Instead we try to see whether the person, generically, has a personality disorder. Only after this do we diagnose a particular disorder.
The diagnostic technique depends on figuring out two things. First, does the person have something called identity diffusion? Second, does the person rely on splitting defense mechanisms. If the answer to both these questions is “no” they do not have a personality disorder. If the answer to both these questions is “yes,” they do. Then you take more of a history to figure out which PD they have. In most PD circles, it doesn’t particularly matter which PD they have because in the end what you are trying to fix is the identity diffusion and the splitting defense mechanisms.
So what is identity diffusion? It’s a complex question and most textbooks spend hundreds of pages exploring its nuances. But in very broad strokes, people without identity diffusion “are comfortable in their own skin” and “know who they are” are “true to themselves” and are empathic towards others; they make other people “feel seen” and respected and appreciated. They don’t treat other people as interchangeable. They act and think the same from day to day; they don’t have major fluctuations in whether they like or don’t like themselves, like or don’t like other people, feel optimistic or pessimistic about their lives, and so forth. Identity diffusion is the opposite. I can say more about this if you like.
Splitting is easier to understand – in lay terminology its “black and white” or “all or nothing” thinking. People who use splitting defenses tend to love or hate people, and to describe them in either idealizing or devaluing terms. This applies to themselves also. They tend to either put themselves down, hate themselves, loathe themselves or to act arrogant, entitled, and so forth. Typically the splits wobble back and forth, so that sometimes they love and sometimes they hate the same person. Couples who keep breaking up and getting back together often have at least one member who is using splitting defenses.
We spend hours – in my practice I can spend ~4 sessions when first meeting someone – trying to figure this out, because you can’t ask someone straight-up “do you use splitting defenses?” You need to hear lots of anecdotes before you get a sense, and often you need to get collateral information from a family member. Over that time period it emerges that they are narcissistic, avoidant, borderline, histrionic and so forth. But as a shrink – at least in my field, which focuses on the psychodynamic treatment of personality disorders – you are more or less focused singlemindedly on their identity structure, their sense of self, and their defense mechanisms.


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